Inspection Report
Follow-Up
Census: 149
Capacity: 190
Deficiencies: 1
Jan 28, 2025
Visit Reason
The inspection visit on 01/28/2025 was conducted as a follow-up to review the submitted plan of correction related to an incident involving resident abuse.
Findings
The investigation substantiated abuse by a contracted agency staff member who threw a leg brace at a resident. The staff member was suspended and terminated. The facility implemented additional training and monthly resident interviews to prevent future abuse.
Deficiencies (1)
| Description |
|---|
| A contracted agency staff member threw a leg brace at a resident, causing emotional distress but no physical injury. |
Report Facts
Residents Served: 149
License Capacity: 190
Residents Served in Secured Dementia Care Unit: 38
Residents with Mobility Need: 50
Residents Age 60 or Older: 149
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 2
Inspection Report
Renewal
Census: 154
Capacity: 190
Deficiencies: 5
Nov 5, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation for Messiah Lifeways at Messiah Village.
Findings
The report found deficiencies related to resident personal equipment, unobstructed egress, support plan medical/dental, self-administration of medication, and no objection statements for secured dementia care unit admissions. Plans of correction were accepted and implemented by early January 2025.
Deficiencies (5)
| Description |
|---|
| The bed of a resident had 1/2 bed rails on both sides with openings posing an entrapment risk. |
| The second floor door leading from the Nittany neighborhood to the secured Laurel neighborhood was locked and the keypad disabled, preventing access. |
| The support plan for a resident did not indicate that the resident utilizes bedrails. |
| Resident's support plan stated inability to self-administer medications, but physician orders indicated ability to self-administer some medications. |
| No documentation that a resident and their designated person did not object to admission to the secured dementia care unit. |
Report Facts
License Capacity: 190
Residents Served: 154
Secured Dementia Care Unit Capacity: 76
Secured Dementia Care Unit Residents Served: 75
Current Hospice Residents: 2
Residents with Mobility Need: 54
Residents Age 60 or Older: 154
Inspection Report
Renewal
Census: 119
Capacity: 190
Deficiencies: 14
Jan 23, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of the facility Messiah Lifeways at Messiah Village during unannounced visits on 01/23/2024, 01/24/2024, and 01/25/2024.
Findings
The inspection identified multiple deficiencies including commingling of resident funds, lack of required annual staff training, hot water temperature exceeding limits, snow removal issues, inadequate fire drills during sleeping hours, incomplete medical evaluations and assessments for residents, missing items in first aid kits, expired medications, unsecured resident records, and incomplete support plans and screenings. All deficiencies had corrective action plans accepted and were implemented by 02/20/2024.
Deficiencies (14)
| Description |
|---|
| Commingling of resident funds and home funds with resident funds placed in a shared bank account owned by the home. |
| Staff person A did not receive required annual training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, and falls and accident prevention. |
| Hot water temperature in the bathroom of resident room #192 measured 124.4°F, exceeding the 120°F limit. |
| Walkway in courtyard and bottom of large white gate were covered with approximately 2 inches of snow. |
| Fire drills during sleeping hours were not held at least every 6 months; last drill was 9/27/23 and previous was 9/28/22. |
| Medical evaluations were not completed within required timeframes for several residents including Residents 3, 4, 5, and 6. |
| First aid kit in the Dodge Caravan used for resident transportation lacked eye coverings/goggles. |
| Expired PRN medications were found in the medication cart for Resident 9. |
| Preadmission screening forms were not completed for several residents admitted between 2018 and 2024 including Residents 3, 4, 5, and 6. |
| Initial written assessments were not completed within 15 days of admission for several residents including Residents 3, 4, 5, and 6. |
| Several residents including Residents 3 and 4 did not have current annual resident assessment/support plans (RASPs). |
| Initial written support plans were not completed within 30 days of admission for several residents including Residents 3, 4, 5, and 6. |
| Residents 7 and 8 in the Secure Dementia Care Unit did not have assessment/support plans addressing the need for this level of care. |
| Records for Residents 10 and 11 were unlocked, unattended, and accessible in the nurse's office and staff break room. |
Report Facts
Inspection Dates: 3
Residents Served: 119
License Capacity: 190
Secured Dementia Care Unit Capacity: 42
Secured Dementia Care Unit Residents Served: 25
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 25
Residents with Physical Disability: 2
Inspection Report
Complaint Investigation
Census: 117
Capacity: 190
Deficiencies: 3
Oct 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse involving sexual acts witnessed by a staff member in the independent living wing of the facility.
Findings
The investigation found that two separate incidents of sexual acts involving a resident with memory impairment were witnessed but not reported immediately as required by law. Staff education on abuse reporting and consent was initiated following the incidents, and a plan of correction was accepted and implemented.
Complaint Details
The complaint involved two separate incidents in August where a resident in the independent living wing performed sexual acts on another resident with memory impairment. The incidents were not reported timely to the local Area Agency on Aging or the Department. Staff Member A delayed notifying the Administrator, who then ensured immediate reporting and staff education on abuse reporting requirements.
Deficiencies (3)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act. |
| Failure to report the incident to the Department’s personal care home regional office or complaint hotline within 24 hours. |
| Resident subjected to sexual abuse, violating prohibition against neglect, intimidation, or abuse. |
Report Facts
License Capacity: 190
Residents Served: 117
Secured Dementia Care Unit Capacity: 76
Secured Dementia Care Unit Residents Served: 59
Hospice Current Residents: 9
Residents with Mobility Need: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryn Tyrrell | Administrator | Named in education and reporting requirements related to abuse incidents |
Inspection Report
Census: 120
Capacity: 190
Deficiencies: 0
Jul 11, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason stated as 'Incident'.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 185
Waking Staff: 139
License Capacity: 190
Residents Served: 120
Secured Dementia Care Unit Capacity: 76
Secured Dementia Care Unit Residents Served: 64
Current Hospice Residents: 2
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 65
Residents Age 60 or Older: 120
Inspection Report
Follow-Up
Census: 120
Capacity: 190
Deficiencies: 1
Jun 6, 2023
Visit Reason
The inspection visit on 06/06/2023 was a partial, unannounced follow-up triggered by a complaint and incident.
Findings
The report found a violation related to the treatment of residents, specifically verbal abuse by a staff member towards a resident. The staff member was suspended and subsequently terminated. Additional training on verbal abuse and resident rights was initiated.
Complaint Details
The visit was complaint-related and involved an incident of verbal abuse. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Staff Person A was heard speaking loudly and in a disrespectful manner to Resident #1, including saying 'I don’t like you either' and forcibly closing the resident's door. |
Report Facts
Residents Served: 120
License Capacity: 190
Secured Dementia Care Unit Capacity: 76
Secured Dementia Care Unit Residents Served: 62
Current Hospice Residents: 3
Residents Age 60 or Older: 120
Residents with Mental Illness: 1
Residents with Physical Disability: 1
Residents with Mobility Need: 65
Inspection Report
Follow-Up
Census: 126
Capacity: 190
Deficiencies: 5
Mar 28, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to multiple deficiencies including resident abuse reporting, record confidentiality, activities of daily living assistance, unobstructed egress, and medication security. Continued compliance and ongoing audits were mandated.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected physical and verbal abuse of residents to the local area agency on aging. |
| Controlled substances binder containing resident names and prescribed medications was unlocked, unattended, and accessible. |
| Resident did not receive required assistance with activities of daily living as indicated in the support plan. |
| Door next to bedrooms 205 and 206 could not be opened using the electronic keypad due to lock malfunction. |
| Half of a small blue tablet was observed on the carpet next to a medication cart, indicating medication security breach. |
Report Facts
License Capacity: 190
Residents Served: 126
Secured Dementia Care Unit Capacity: 76
Residents Served in Dementia Care Unit: 39
Current Hospice Residents: 2
Residents Age 60 or Older: 126
Residents with Mental Illness: 1
Residents with Physical Disability: 1
Residents with Mobility Need: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Counseled nurse on medication administration violation and responsible for conducting compliance audits. |
Inspection Report
Renewal
Census: 120
Capacity: 190
Deficiencies: 7
Nov 30, 2022
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction for the facility.
Findings
Multiple deficiencies were identified including unsecured enabler bars posing entrapment risks, incomplete first aid kit, lack of operable bedside lighting for a resident, unlocked medication cart, inaccurate glucometer documentation, unavailable prescribed medication, and delayed admission support plan completion. All deficiencies had plans of correction accepted and were implemented by the end of December 2022.
Deficiencies (7)
| Description |
|---|
| Uncovered and unsecured enabler bars on residents' beds posing entrapment risks. |
| First aid kit located in Upper Laurel missing tweezers. |
| Resident #5 lacked access to an operable lamp or other source of lighting at bedside. |
| Medication cart labeled 'HW-1' was unlocked, unattended, and accessible in the Hopewell Neighborhood. |
| Resident #6’s glucometer reading did not match the Medication Administration Record. |
| Resident #5’s prescribed PRN medication was not available in the home on 12/1/22. |
| Resident #7’s admission support plan to the secured dementia care unit was not completed within the required 72 hours. |
Report Facts
Residents Served: 120
License Capacity: 190
Residents Served in Secured Dementia Care Unit: 66
Capacity of Secured Dementia Care Unit: 76
Current Hospice Residents: 4
Residents with Mobility Need: 67
Residents 60 Years or Older: 120
Residents Diagnosed with Mental Illness: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse | Nurse administering medications from the unlocked medication cart was notified and counseled. | |
| Director of Nursing | Counseled the nurse responsible for the unlocked medication cart and conducted audits. | |
| Staff Educator | Provided education to team members regarding various deficiencies and compliance requirements. | |
| Administrator | Placed night light for Resident #5 and educated social workers on admission support plan requirements. | |
| Clinical Manager | Conducted audits related to first aid kit compliance and medication administration. | |
| Social Worker | Responsible for educating residents about enabler bars and admission support plan compliance. |
Notice
Capacity: 238
Deficiencies: 0
Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Messiah Lifeways at Messiah Village, a Personal Care Home, following receipt of a renewal application dated July 13, 2021.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with Title 55, PA Code, Chapter 2600, and enforcement actions will be taken if noncompliance is found.
Report Facts
Maximum capacity: 238
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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